Ramon De La Garza
Pflugerville,TX
Summary
Outgoing with experience overseeing multiple tasks and managing employees successfully. Hardworking professional committed to providing outstanding customer service and assistance.
Overview
15
15
years of professional experience
1
1
Certification
Work History
Senior Appeals Coordinator
UnitedHealthcare
Oldsmar, FL
06.2017 - Current
- Acted as subject matter expert, answering internal and external questions and inquiries.
- Made contact with non-participating providers to discuss policies and individual patient benefits.
- Communicated effectively with staff members of operations, and clinical departments.
- Acted as subject matter expert, answering internal and external questions and inquiries.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
- Ensure complaint has been categorized correctly.
- Obtain additional documentation required for case review.
- Review case to determine if review by clinician is required.
- Render decision for non-clinical complaints using sound, fact-based decision making.
- Complete necessary documentation of final appeals or grievance determination using appropriate templates.
Supervisor
UnitedHealthcare
Oldsmar, FL
08.2016 - 06.2017
- Applied strong leadership talents and problem-solving skills to maintain team efficiency and organize workflows.
- Handled customer complaints, resolved issues and adjusted policies to meet changing needs.
- Evaluated employee performance and coached and trained to improve weak areas.
- Maintained compliance with company policies, objectives and communication goals.
- Worked with management team to implement proper division of responsibilities.
- Mentored newly hired employees on department policies and practices.
- Interviewed, hired and trained new employees.
- Identified individual employee's unique work styles and adapted management methods.
- Performed annual evaluations and reviews.
- Coordinate and supervise daily/weekly/monthly activities of a 20-person team including setting priorities for the team to ensure task completion and performance goals are met.
- Coordinate work activities with other supervisors, managers, departments, etc.
- Identify and resolve operational problems using defined processes, expertise and judgment.
- Provide coaching, feedback and annual performance reviews as well as formal corrective action
- Communicate with appropriate parties regarding appeals and grievance issues, implications and decisions.
- Analyze and identify trends for all appeals and grievances.
- Established and updated work schedules to account for changing staff levels and expected workloads.
- Hired, managed, developed and trained staff, established and monitored goals, conducted performance reviews.
- Completed bi-weekly payroll for 20 employees.
- Mentored office employees on proper administrative procedures and how to use programs, keeping operations consistent and efficient for maximum performance.
Appeals Coordinator
UnitedHealthcare
Oldsmar, FL
03.2007 - 07.2016
- Research and resolve written complaints submitted by consumers and physicians/providers.
- Ensure complaint has been categorized correctly.
- Obtain additional documentation required for case review.
- Review case to determine if review by clinician is required.
- Render decision for non-clinical complaints using sound, fact-based decision making.
- Complete necessary documentation of final appeals or grievance determination using appropriate templates.
- Communicate appeal or grievance information to members or providers and internal/external parties within the required timeframes.
- Assist other teams.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
- Made contact with non-participating providers to discuss policies and individual patient benefits.
- Communicated effectively with staff members of operations, finance and clinical departments.
- Acted as subject matter expert, answering internal and external questions and inquiries.
Education
No Degree - Physcology
Univeristy of South Florida
Tampa, FLAssociate of Arts - General Studies
Texas Southmost College
Brownsville, TXSkills
- Staff Training
- Team Management
- Benefits Coordination
- Filing Appeals
- Word Processing
- Prioritizing Workflows
- CMS Guidelines
- Friendly and Relatable
- Meeting Coordination and Support
- Remote Work Coordination
Certification
- Certified Six Sigma Yellow Belt
Languages
Spanish
Native or Bilingual
Timeline
Senior Appeals Coordinator
UnitedHealthcare
06.2017 - Current
Supervisor
UnitedHealthcare
08.2016 - 06.2017
Appeals Coordinator
UnitedHealthcare
03.2007 - 07.2016
No Degree - Physcology
Univeristy of South Florida
Associate of Arts - General Studies
Texas Southmost College
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